Do we over investigate older people?

A medical approach to someone based solely on their age is, particularly since the passing of the Equality Act 2010, illegal and wrong. However, a tailored approach based on need and likely response to treatment is perfectly sensible. We would not treat an 18 month old toddler in a similar way to a 52 year old, but we don’t want to over investigate older people either.

The important aspect is recognising the physical and mental changes that accompany the passing of years. This is not rationing, where treatment or investigation is guided by resource availability, but rather a balance between the benefit and burden of an action.

The case example below highlights the question of do we over investigate older people? The spoiler answer: Sometimes, but less so than you think.

Protecting patients from doctors

Many older people do not want medical intervention, and have a strong sense of fatalism that is natural at advanced age. Often people like this, vulnerable with acute illness, hard of hearing, separated from loved ones in an unfamiliar place, can be easily persuaded to undergo a scan or an endoscopy which starts a cascade of medicalisation.

It is not uncommon to discuss an upcoming investigation and hear “I don’t know why they’re doing this” or “I don’t want any of it, really”. To not do something is difficult for the physician who’s central role is to improve health. How many of us have wanted to reach for the prescription pad, but eventually relented knowing the patient just doesn’t want to have their medication changed again?

Is the NHS too keen to over investigate older people?

Is the UK particularly keen on putting older people through the scanner? There is a perception that we increasingly fruitlessly investigate older people.¹ Medical spending in the last twelve months of life accounted for approximately 8-11% of aggregate medical spending in most countries.

Data is difficult to compare due to variation in funding models and medical/social care splits, but it’s likely that the UK spends less than other countries on medical care in the last year of someone’s life.² There is thus already rationalisation (hopefully) of investigation and treatment, or prejudice.

Frailty as a guiding metric

The World Health Organization’s definition of health is “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.” Frailty, by contrast, is a concept of accumulated deficits making the WHO state of complete health impossible. It is challenging for doctors to distinguish frailty from ageing marred by a disease state. It is key for recommending medical intervention to do so:  in advanced frailty, where mortality risk is high and daily functional limitations are faced regardless, medical interventions and investigations are of questionable utility.

However, an older patient with little significant frailty may well be able to be treated and granted an improved quality and quantity of life (actuarial life expectancy for an 85 year old man is on average 6 years in the UK). How to distinguish frailty and ageing with disease is not the scope of this article, but is worth posing as a framing question.

The concept of whether to intervene in frail patients has been discussed for many years. Twenty years ago, the BNF described antihypertensives as “clearly unsuitable for the elderly”, whereas there is data now to support blood pressure reduction in the oldest old. When one factors in frailty, the benefits of intervention are not seen.³ The idea that therapy can be targeted on the basis of frailty is increasingly widespread. Diabetes management takes frailty into account,⁴ as does choosing the best way to investigate coronary disease.⁵

Patient autonomy means discussion

Rational investigation is underpinned by the question all ward rounds should echo to at some point “and how is that going to change management?” Usually if a test finds pathology, the next step is to tackle that finding. If all possible courses of action from a positive finding lead to intervention or further investigation that will prove more burdensome than beneficial, then the test should not have been undertaken.

Better then to discuss what a test might yield with the patient or family. This can be difficult. Conveying nuance around relative merits of treatment involves many hypotheticals and can be a struggle to explain fully, especially where cognitive impairment is also an issue. Most physicians will have experience of this around discussion of treatment escalation plans or resuscitation decisions. These, even with this extreme but clear cut decision, can be problematic in an acute setting.⁶

Hypothecated scenarios do tend to work better than general discussions. Work has been done in primary care to promote discussion around future care wishes.⁷ This proactively sought decision making, but focused on extreme interventions (resuscitation, ventilation) rather than the relative burden and benefit of general investigations.

“Anticipatory care in three questions” was the RCGP’s bright idea winner in 2018. In primary care a questionnaire was used asking someone and their family what they would want in the event of

• a sudden collapse?
• an infection not responding to antibiotics?
• an inability to eat and drink due to illness?

Their finding was increased engagement in making decisions around whether possible hospitalisation or intervention was wanted. A focus on how we honestly describe often complex natural histories of disease processes to bemused non-specialists is necessary. The shepherd cannot understand how ramblers are unable to recognise one sheep from another, and physicians often underestimate how difficult taking medical decisions on can be. Hypothecated questions can be useful here.

Common examples

Few dilemmas are commoner than iron deficiency anaemia. This is widespread in advanced frailty, indeed it may be a marker of frailty. Anaemia in older people has many causes, many of which may be present at once, but blood indices may point to a iron deficiency commonly (around 25% of older people).⁹ The British Society of Gastroenterology cites that the priority is the discovery of asymptomatic colonic or gastric cancers.¹⁰ However, investigation can be uncomfortable and colonoscopy is potentially dangerous in very frail patients ¹¹. Even bowel preparation itself may carry risk.^12 13 Ct colonoscopy is an alternative but less sensitive.¹⁴ If surgery is undertaken, 30 day mortality and complication rate is twice that of non-frail patients.

If a conservative strategy is followed then average life expectancy was 1.5 years in a group aged 77 to 93 with significant frailty. With surgery, 50% of patients will survive 5 years, with 12% requiring new institutionalisation after intervention and 70% experiencing a reduction in their functional status. The data is thus mixed- people do benefit from surgery even at advanced age, but with greater frailty the risk of unintended consequences or functional decline rise.¹⁰

Unintentional weight loss is another common feature of ageing, and was the subject of an excellent review by McMinn in 2011.¹⁵ The key points are history and an appraisal in the round (58% of care home residents experience weight loss from depression or dementia rather than a malignancy, for example) is more useful than investigating first.

Consequences of not investigating older people

If one is not to treat or investigate, then management becomes palliative. This is the consequence of not pursuing an active therapeutic strategy and must be explicit in discussions. The extent of investigation in palliative patients has been described.¹⁶ There is a grey area of increasing frailty where a strictly palliative pathway has not been designated but there may be misgivings on the part of the patient, family or medical team as to the quantum of benefit versus burden.

Comprehensive geriatric assessment is aimed at gaining an overview on how an individual is limited by all aspects of the ageing or frailty process. It thus should provide the backdrop to rational decisions around treatment and investigation. One study looking at its application in cancer patients found it did not alter decisions to treat, but did yield useful extra support for functioning at home.¹⁷

The CGA has also been used to minimise harm from polypharmacy and unnecessary hospital admission.¹⁸

Conclusion

Many health risks are a matter of choice, even, apparently, a raised body mass index. Avoidance of old age is a drastic choice, and as such most of us will face a portion of our lives in frailty. Who can put a price on those years? Who will regard with indifference seeing grandchildren, continuing to enjoy the acoustic years of Bob Dylan or revisiting  arguments with friends on the shortcomings of the Arsenal defensive line up? For some of us, those will be hard times, and we may find the prospect of more years, enduring more discomfort and limitation, unappealing. Medical science will have moved on, so a careful discussion around treatment options, together with family or trusted friends, will be welcome.

It is up to us to facilitate such an approach now. Evidence does support intervention at advanced age. Evidence also supports using the identification and measurement of frailty as a guide to the merits of starting on a medical intervention pathway. However, any judgement will be nuanced and the communication of this is challenging. Geriatricians will always be happy to help, but ultimately the goal is to enable the affected individual to make a decision they are content with.

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Dr Andrew Stone, Consultant Physician, Royal United Hospitals Bath

[email protected]

Conflict of interest: none declared

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References

1. Fawcett, R, and P McCoubrie. Pitfalls in imaging the frail elderly. The British Journal of Radiology vol. 88,1045 (2015): 20140699. doi:10.1259/bjr.20140699
2. Eric B. French, Jeremy McCauley, Maria Aragon, Pieter Bakx, Martin Chalkley . Advanced illness and End of Life Care. VOL. 36, NO. 7: End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported; https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0174
3. Todd, O et al. Is the association between blood pressure and mortality in older adults different with frailty? A systematic review and meta-analysis . Age and Ageing 2019; 48: 627-635 doi: 10.1093/ageing/afz072
4. Strain, WD et al. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine 2018; 35 (7): 838-845
5. Qingyu Dou et al. Prognostic value of frailty in elderly patients with acute coronary syndrome: a systematic review and meta-analysis. BMC Geriatr 19, 222 (2019). https://doi.org/10.1186/s12877-019-1242-8
6. Hall CC, Lugton J, Spiller JA, et al. CPR decision-making conversations in the UK: an integrative review. BMJ Supportive & Palliative Care 2019;9:1-11
7. Dunphy EJ, Conlon SC, O’Brien SA, Loughrey E, O’Shea BJ. End-of-life planning with frail patients attending general practice: an exploratory prospective cross-sectional study. Br J Gen Pract. 2016;66(650):e661-e666. doi:10.3399/bjgp16X686557
8. https://www.rcgp.org.uk/clinical-and-research/resources/bright-ideas/anticipatory-care-planning-in-three-questions.aspx ix Goodnough LT, Schrier SL. Evaluation and management of anaemia in the elderly. Am J Hematol. 2014;89(1):88-96. doi:10.1002/ajh.23598 x https://www.bsg.org.uk/clinical-resource/guidelines-for-the-management-of-iron-deficiency-anaemia/
9. Lin OS. Performing colonoscopy in elderly and very elderly patients: Risks, costs and benefits. World J Gastrointest Endosc. 2014;6(6):220-226. doi:10.4253/wjge.v6.i6.220
10. Crozier-Shaw , Too frail for surgery? A frailty index in major colorectal surgery;  ANZ Journal of Surgery, Volume88, Issue12, Pages 1302-1305
11.  Judith S. L. Partridge, Danielle Harari, Jugdeep K. Dhesi; Frailty in the older surgical patient: a review ;  Age and Ageing, Volume 41, Issue 2, March 2012, Pages 142-147
12. L J Neilson, S Thirugnanasothy, C J Rees. Colonoscopy in the very elderly. British Medical Bulletin, Volume 127, Issue 1, September 2018, Pages 33-41
13. Rapid Response Report: Reducing risk of harm from oral bowel cleansing solutions. National Patient Safety Agency 2009; Available from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=59869
14. Duarte RB, Bernardo WM, Sakai CM, et al. Computed tomography colonography versus colonoscopy for the diagnosis of colorectal cancer: a systematic review and meta-analysis. Ther Clin Risk Manag. 2018;14:349-360. Published 2018 Feb 21. doi:10.2147/TCRM.S152147
15. McMinn Jenna, Steel Claire, Bowman Adam. Investigation and management of unintentional weight loss in older adults BMJ 2011; 342 :d1732
16. M Cardona-Morrell, JCH Kim, RM Turner, M Anstey, IA Mitchell, K Hillman, Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem, International Journal for Quality in Health Care, Volume 28, Issue 4, September 2016, Pages 456-469, https://doi.org/10.1093/intqhc/mzw060
17. Handforth, C., Burkinshaw, R., Freeman, J. et al. Comprehensive geriatric assessment and decision-making in older men with incurable but manageable (chronic) cancer. Support Care Cancer 27, 1755-1763 (2019). https://doi.org/10.1007/s00520-018-4410-z
18. Safe, compassionate care for frail older people using an integrated care pathway, NHS England 2014. https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf